Frozen Shoulder

‘Frozen shoulder’, adhesive capsulitis and periarthritis are some of the many synonyms used to describe a condition that is frequently seen by the physiotherapists (and our psychologist) at bounceREHAB. Although there are certain aspects of the condition that still generate debate, clinical features make it relatively easy to recognise after a certain period of time. Frozen shoulder occurs when the connective tissue enclosing the joint becomes thickened and tight.

Generally it has a spontaneous onset affecting people > 40 years, sometimes following periods of immobility (rotator cuff surgery) or perhaps a fall onto an outstretched arm. In the cases that somebody had a fall or surgery the pain can be felt immediately and the stiffening progresses rapidly.

Frozen shoulder Man1        Frozen shoulder man2

It is said that frozen shoulder goes through 3 stages. The stages of frozen shoulder are overlapping:

  • FREEZING         2  –>  9 months
  • FROZEN            4 –> 12 months
  • THAWING        12  –>  48 months+

The mean duration of symptoms from onset to recovery has been shown to be 12 – 36 months.  The average timeframes of each stage is known to vary significantly between individuals.

Research and our clinical observation suggest that if you have frozen shoulder you may feel the following symptoms classically within each stage:

  • FREEZING               –> PAIN is at its very worst point (chemical pain).
  • FROZEN                   –> PAIN + STIFF shoulder (chemical and mechanical pain)
  • THAWING                –> STIFFNESS improving

0                    3-6                                                       MONTHS                                12-18                                     36

<–  —————————————————————–!————————————————————– –>

CHEMICAL PAIN                                                   MIXED                                                  MECHANICAL PAIN

STAGE 1                                                                  STAGE 2                                                  STAGE 3

PASSIVE – Pain Management                        TREATMENT                                 ACTIVE – Physio/exercises

So, now that we are aware that frozen shoulder has 3 particular stages, the pain and movement loss are being caused by two very different mechanisms in your body, treatment should be carefully tailored to each person. You may have heard of 1 person that had a great response to one therapy (e.g. steroid injection) and then the next individual has suffered a pain flare up from the very same therapy.

In order to successfully progress this condition along the natural healing continuum it is very important to understand the difference between CHEMICAL and MECHANICAL pain. It is also very important that those with frozen shoulder be made aware that their condition is self-limiting and that in time, even without treatment the pain will settle down. However,

nearly 50% of patients who were followed over many years reported symptoms of residual restricted mobility. 

Chemical pain is pain caused by an inflammatory or chemical process. Pain is constant 24/7 from the time of waking up to the time you fall asleep. This pain is relentless and doesn’t like being prodded or poked by anyone.

Mechanical pain is pain caused by our musculoskeletal system (e.g. tight muscles or repetitively loading joints with bad posture). Pain can be altered by movement or physiotherapy techniques.

Just to make things more confusing, many researchers are now looking into whether changes in our neuroscience (the brainstem-cervical spine or neck) are a contributing factor to frozen shoulder. Don’t forget that the nerves in the shoulder exit via the neck joints so this influence should never be overlooked. I will admit that I have a tendency (as a physiotherapist) to treat the secondary changes (i.e. stiff and sore neck, weakness of the shoulder blades and neck muscles) of frozen shoulder with appropriate depths of massage therapy, joint mobilisations and specific postural exercises.
Watch this you tube video for more on these latest neurobiological changes that may cause the condition (WARNING – jury is still out).

Management Strategies of Frozen Shoulder

Click on the link below to go to Facebook to view frozen shoulder exercises
 Post by bounceREHAB.

Management and treatment should be guided by the stage of the condition.

 ‘Freezing’ Stage 1 – Education, Education, Education!
  • Medications like NSAID’s or cortisone injections (poor evidence for effectiveness long term)
  • TENS (electrical impulses) portable home device (demonstration from your physiotherapist is encouraged to maximise effectiveness)
  • Dry Needling (acupuncture)
  • Hot/Cold packs
  • Light pain free movements only
  • Avoid aggravating factors (repetitive reaching and gripping activities)
  • Get a low or high profile pillow to properly support your neck and reduce shoulder tension (bounceREHAB recommend a Dentons pillow $70)
‘Frozen’ Stage 2 – Frustrating period!
  • Medications like analgesics (pain killers)
  • Light pain-free strengthening exercises
  • Soft tissue therapy (physio) for reducing neck pain / headaches, joint and nerve tightness
  • Avoid aggravating factors (poor posture, sleeping on shoulder, repetitive reaching)
‘Thawing’ Stage 3 – PHYSIO, PHYSIO, PHYSIO!
  • Active approaches such as physiotherapy guided exercises to improve your shoulder joint movement.
  • It is important that physiotherapists help you target certain movements before other movements can be successfully attained. For example, we find that you should improve reaching forwards (flexion) first, then, improve hand behind your back (internal rotation), then, hand on your head (external rotation and abduction).
  • We can then progress to a weights program where necessary or a Pilates endurance program for reconditioning the scapula, thoracic and neck muscles.
  • Surgery – manipulation under anaesthesia (MUA) is not likely to help or speed things up. This is usually a very desperate measure that will cause further soft tissue damage and may have long term consequences such as causing bone fractures to the humerus. Joint distention and capsular surgeries are other procedures that orthopaedic surgeons can perform.
The role of physiotherapy and psychology (pain management)

At bounceREHAB we are well positioned to help those of you out there that have a frozen shoulder. Due to the debilitating and distressing nature of this condition we often see patients that have been living with this condition for lengthy periods of time. Most of these people have been told by their GP doctor that there is ‘nothing you can do about it’ and that treatment is a ‘waste of time, effort and money’. By the time these people have attended our clinic they have already developed many of the following problems that can stem easily from not understanding the natural history or stages of the condition:

  • Frustration –> stress <– anxiety
  • Depression or low mood –> social isolation
  • Pain medication dependencies
  • Unfit for work due to pain and functional loss of arm movements
  • Insomnia – not sleeping
  • Loss of short term memory (cognitions)
  • Fear of movement causing pain and muscle wastage

It has been demonstrated that you will be more in control of the above psychological and physical issues related to your pain if you simply understanding your ‘condition’ more. It is up to you to get educated (Butler & Mosley).

It is also very important that in Stage 1-2 you acknowledge and accept that you cannot live by the mantra ‘no pain no gain’ or pretend that the pain is not there. It simply doesn’t work with Stage 1-2.

This will likely make your frozen shoulder last a lot longer than if you humbly worked within your pain limit and continued to do easy movements with minimal pain.  A thorough explanation to the science of pain and what can ‘fire up’ or ‘cool down’ our nerves is essential for making intelligent daily lifestyle decisions. Additionally, using active coping strategies (self-management) will allow you to minimise your pain levels each day, improving your ability to sleep (heal) and hopefully rely much less on medication and other treatments such as physiotherapy or surgical procedures.

bounceREHAB combines the skills of both physiotherapist & psychologist. We use a team approach to treating your frozen shoulder. We have found that having a combined treatment approach allows you to better address the many physical and psychological barriers all under the same roof. Many of the physical issues can cause or heighten the psychological issues and vice versa. It is important to learn that there is a strong link here between mind and body.

QUICK RESEARCH SUMMARY – It is all over the shop :(
  • Many of the studies identified were at high risk of bias and poor quality
  • 2 trials showed that there may be benefit from adding physiotherapy (including
  • mobilisation) to a single steroid injection
  • 9 studies found that steroids combined with physiotherapy was the only treatment showing a statistically and clinically significant beneficial treatment effect compared with placebo for short-term pain
  • No studies of patients’ views about the treatments were identified.
  • 1 published economic evaluation suggested that low-grade mobilisation may be more cost-effective than high-grade mobilisation

For more information about the bounceREHAB program structure please contact us at admin@bouncerehab.com.au

RECENT RESEARCH FINDINGS

I encourage all of my patients with frozen shoulder to scan read the latest systematic review  

E Maund et al (2012) Management of frozen shoulder: a systematic review and cost-effectiveness analysis http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0047025/pdf/TOC.pdf

 

USEFUL PRODUCTS FOR OPTIMAL SELF MANAGEMENT SOLD AT BOUNCEREHAB ONLINE SHOP:

TENS portable devices $190

Dentons Pillows $70

Anti-Flamme topical cream $25 (90grams)

Heat packs $25

Cold Compression Cryocuff Hire $30 per week

Pilates Home Kits (exercise tubing) $29 or Theraband $10/meter

Shoulder Door Pulleys $20         

Foam Rollers – small $30 large $50

T-rack $135

As our online store is currently under constructions please contact admin@bouncerehab.com.au for orders

 

Matthew Craig
DIRECTOR / PHYSIOTHERAPIST
B.App.Sci (Physiotherapy), CSCS (Strength and Conditioning Specialist)
National Advisory Board CPAA (Chronic Pain Association of Australia)
DIRECTOR Bounce Rehab PTY